DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left hip wound infection.
POSTOPERATIVE DIAGNOSIS: Left hip wound infection.
PROCEDURE PERFORMED: Left hip wound incision and drainage.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 250 mL.
INDICATIONS FOR PROCEDURE: This patient is a (XX)-year-old female with a history of total hip arthroplasty on the left side. She was seen and admitted for erythema and copious drainage from her hip wound. She understands the risks, benefits and alternatives of the procedure, including potential for eventual explantation of her hip prosthesis if there is synovial infection.
DESCRIPTION OF PROCEDURE: The patient was correctly identified, and preoperative antibiotics were withheld until cultures could be drawn. She was brought to the operating room and placed supine on the operating room table. After the induction of general endotracheal anesthesia, the patient was propped up into sloppy lateral position using a gel roll under the left buttock. All pressure points were well padded. The left hip was then prepped and draped in the usual sterile fashion.
The patient’s wound was opened along the previous incision site using the 10 blade. Upon entering the subcutaneous fatty layer, there was noted to be large amounts of necrotic fat. There was some purulence noted with this as well. This was removed by the handful. The wound was then preliminarily irrigated using Pulsavac irrigation. The Cobb was then used to scrape the exposed fatty surfaces down to a more healthy-appearing layer. The patient did have significant amount of subcutaneous fat, and her fascial layer was noted to be quite deep in the wound. This was palpated. There was a small rent noted in the deep fascia; however, there was no purulence or drainage expressible from that rent.
The wound was thoroughly irrigated with 9 liters of pulsatile saline lavage, the central three liters of which contained bacitracin. Superficial and deep cultures were sent and 0 Prolene was used to close down the deep fatty layer, and a large Hemovac drain was placed. The skin was then closed with a running 0 Prolene suture. The patient was awoken and was taken to the recovery room in stable condition.
